Application intake form
Use the form below to submit a request for emergency assistance review. After submission, a reference ID is generated for tracking.
Before submitting
- Use your full legal name
- Provide a working email address
- Enter a phone number where you can be reached
- Describe your situation clearly and briefly
- Submit only one request per situation
A reference number is created after submission and used for future tracking.
JIT-EX assistance intake
If the embedded form does not load properly on your device, open the application in a separate tab.
After submitting, monitor your email and use the status page with your reference ID.
Submitting an intake request does not guarantee approval, eligibility, or payment.